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. 2021 Dec 20:2:100853.
doi: 10.1016/j.bas.2021.100853. eCollection 2022.

Assessment of the incidence and nature of adverse events and their association with human error in neurosurgery. A prospective observation

Hanno S Meyer  1 , Arthur Wagner  1 , Thomas Obermueller  1 , Chiara Negwer  1 , Maria Wostrack  1 , Sandro Krieg  1 , Jens Gempt  1 , Bernhard Meyer  1
Affiliations

Assessment of the incidence and nature of adverse events and their association with human error in neurosurgery. A prospective observation

Hanno S Meyer et al. Brain Spine. .

Abstract

Introduction: Adverse events in surgery are a relevant cause of costs, disability, or death, and their incidence is a key quality indicator that plays an important role in the future of health care. In neurosurgery, little is known about the frequency of adverse events and the contribution of human error.

Research question: To determine the incidence, nature and severity of adverse events in neurosurgery, and to investigate the contribution of human error.

Material and methods: Prospective observation of all adverse events occurring at an academic neurosurgery referral center focusing on neuro-oncology, cerebrovascular and spinal surgery. All 4176 inpatients treated between September 2019 and September 2020 were included. Adverse events were recorded daily and their nature, severity and a potential contribution of human error were evaluated weekly by all senior neurosurgeons of the department.

Results: 25.0% of patients had at least one adverse event. In 25.9% of these cases, the major adverse event was associated with human error, mostly with execution (18.3%) or planning (5.6%) deficiencies. 48.8% of cases with adverse events were severe (≥SAVES-v2 grade 3). Patients with multiple adverse events (8.6%) had more severe adverse events (67.6%). Adverse events were more severe in cranial than in spinal neurosurgery (57.6 vs. 39.4%).

Discussion and conclusion: Adverse events occur frequently in neurosurgery. These data can serve as benchmarks when discussing quality-based accreditation and reimbursement in upcoming health care reforms.The high frequency of human performance deficiencies contributing to adverse events shows that there is potential to further eliminate avoidable patient harm.

Keywords: Health care reform; Outcome assessment, Health care; Patient harm; Patient safety; Postoperative complications; Quality indicators, Health Care.

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Conflict of interest statement

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Figures

Fig. 1
Fig. 1
Severity of Adverse Events. Fig. 1A shows the relative frequency of AE severity grades according to the SAVES-V2 classification for all patients with AEs (squares and straight line), cranial neurosurgery patients (circles and dashed line) and spinal surgery patients (triangles and dotted line). Note that AEs are more severe (grades 3–6) in cranial neurosurgery compared to spinal surgery cases. Fig. 1 B shows that there are more severe AEs in patients with multiple AEs (circles, dashed line) and in patients with an unplanned return to the OR (triangles, dotted line). While the latter had the most grade 3, 4 and 5 AEs, the former had the highest fatality rate (grade 6). Fig. 1 C illustrates that in patients with AEs related to human performance deficiencies (HPD-AEs; circles, dashed line), there was a shift towards more severe AEs (grades 3–5) compared to AE-cases without HPDs (triangles, dotted line). This difference diminished with increasing severity. Of note, the mortality (grade 6) was lower in cases with HPD-AEs. Fig. 1 D shows the relative frequency of AE severity grades according to the Clavien-Dindo classification, analogous to Fig. 1 A. The distribution of AE severity is similar to that based on the SAVES-v2 classification. Abbreviations: SAVES, Spine Adverse Events Severity System; AE, Adverse Event; OR, operating room.
Fig. 1
Fig. 1
Severity of Adverse Events. Fig. 1A shows the relative frequency of AE severity grades according to the SAVES-V2 classification for all patients with AEs (squares and straight line), cranial neurosurgery patients (circles and dashed line) and spinal surgery patients (triangles and dotted line). Note that AEs are more severe (grades 3–6) in cranial neurosurgery compared to spinal surgery cases. Fig. 1 B shows that there are more severe AEs in patients with multiple AEs (circles, dashed line) and in patients with an unplanned return to the OR (triangles, dotted line). While the latter had the most grade 3, 4 and 5 AEs, the former had the highest fatality rate (grade 6). Fig. 1 C illustrates that in patients with AEs related to human performance deficiencies (HPD-AEs; circles, dashed line), there was a shift towards more severe AEs (grades 3–5) compared to AE-cases without HPDs (triangles, dotted line). This difference diminished with increasing severity. Of note, the mortality (grade 6) was lower in cases with HPD-AEs. Fig. 1 D shows the relative frequency of AE severity grades according to the Clavien-Dindo classification, analogous to Fig. 1 A. The distribution of AE severity is similar to that based on the SAVES-v2 classification. Abbreviations: SAVES, Spine Adverse Events Severity System; AE, Adverse Event; OR, operating room.
Fig. 1
Fig. 1
Severity of Adverse Events. Fig. 1A shows the relative frequency of AE severity grades according to the SAVES-V2 classification for all patients with AEs (squares and straight line), cranial neurosurgery patients (circles and dashed line) and spinal surgery patients (triangles and dotted line). Note that AEs are more severe (grades 3–6) in cranial neurosurgery compared to spinal surgery cases. Fig. 1 B shows that there are more severe AEs in patients with multiple AEs (circles, dashed line) and in patients with an unplanned return to the OR (triangles, dotted line). While the latter had the most grade 3, 4 and 5 AEs, the former had the highest fatality rate (grade 6). Fig. 1 C illustrates that in patients with AEs related to human performance deficiencies (HPD-AEs; circles, dashed line), there was a shift towards more severe AEs (grades 3–5) compared to AE-cases without HPDs (triangles, dotted line). This difference diminished with increasing severity. Of note, the mortality (grade 6) was lower in cases with HPD-AEs. Fig. 1 D shows the relative frequency of AE severity grades according to the Clavien-Dindo classification, analogous to Fig. 1 A. The distribution of AE severity is similar to that based on the SAVES-v2 classification. Abbreviations: SAVES, Spine Adverse Events Severity System; AE, Adverse Event; OR, operating room.
Fig. 1
Fig. 1
Severity of Adverse Events. Fig. 1A shows the relative frequency of AE severity grades according to the SAVES-V2 classification for all patients with AEs (squares and straight line), cranial neurosurgery patients (circles and dashed line) and spinal surgery patients (triangles and dotted line). Note that AEs are more severe (grades 3–6) in cranial neurosurgery compared to spinal surgery cases. Fig. 1 B shows that there are more severe AEs in patients with multiple AEs (circles, dashed line) and in patients with an unplanned return to the OR (triangles, dotted line). While the latter had the most grade 3, 4 and 5 AEs, the former had the highest fatality rate (grade 6). Fig. 1 C illustrates that in patients with AEs related to human performance deficiencies (HPD-AEs; circles, dashed line), there was a shift towards more severe AEs (grades 3–5) compared to AE-cases without HPDs (triangles, dotted line). This difference diminished with increasing severity. Of note, the mortality (grade 6) was lower in cases with HPD-AEs. Fig. 1 D shows the relative frequency of AE severity grades according to the Clavien-Dindo classification, analogous to Fig. 1 A. The distribution of AE severity is similar to that based on the SAVES-v2 classification. Abbreviations: SAVES, Spine Adverse Events Severity System; AE, Adverse Event; OR, operating room.
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